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Comment & Response
April 2, 2019

Pharmacist-Led Education to Discontinue Inappropriate Prescribing—Reply

Author Affiliations
  • 1Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
  • 2Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
JAMA. 2019;321(13):1314. doi:10.1001/jama.2019.0311

In Reply We deliberately designed the D-PRESCRIBE study as a pragmatic clinical trial to mirror real-life conditions and test the effectiveness, rather than the efficacy, of the pharmacist-led educational intervention for patients and primary care clinicians.1 The more similar the participants and conditions in a trial are to real life, the more reproducible the findings will be in practice. For this reason, the trial was rolled out in the community, outside of the academic setting, without financial incentives offered to pharmacists or patients. We recruited pharmacies through partnership with 3 large for-profit pharmacy chains serving rural and urban areas in Quebec. Although only half of the eligible pharmacies agreed to participate, and we could not record the profiles of pharmacies that declined, the characteristics of the 69 pharmacies that enrolled in the trial were similar to the characteristics of a population-based sample of 1742 pharmacies in the province of Quebec.2 Pharmacies in the intervention group filled a mean number of 411 prescriptions per day (range, 140-1000), with more than 50% of their clientele composed of adults aged 65 years and older. This large-chain, high-volume prescribing profile of consenting pharmacies compares favorably—and even exceeds—the mean prescription volume reported in 2017 by a random sample of 292 nationally representative community pharmacies in the United States.3 The latter sample of US pharmacies reported a mean prescription volume of 228 prescriptions per day (range, 0-900). Furthermore, the following characteristics of participants in the trial reflected the type of patient that physicians and pharmacists are likely to see in practice: mean age of 75 years (range, 66-96 years) with significant polypharmacy (a mean number of 9 different medications per day [range, 1-28]), frailty rates of 27%, and almost 40% of patients taking more than 10 medications per day. The 2014 EMPOWER trial recruited a comparable sample of pharmacists and patients to an educational deprescribing intervention and achieved discontinuation rates of 27% for chronic benzodiazepine users.4 Taken together, the EMPOWER and D-PRESCRIBE trials provide strong evidence that the deprescribing intervention will work effectively if applied by high-volume, for-profit pharmacy chains in the United States.

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